Advances in cognitive neuroscience make cosmetic neurology in some form inevitable and will give rise to extremely difficult ethical issuesConsider the following hypothetical case study. A well heeled executive walks into my cognitive neurology clinic because he is concerned that he is becoming forgetful. It turns out that he is going through a difficult divorce and my clinical impression is that his memory problems stem from the stress he is experiencing. I place him on a selective seratonin reuptake inhibitor, sertraline, (...) and in a few weeks he feels better. Around this time his 13 year old daughter has difficulty at school and is diagnosed by the school psychologist as having attention deficit disorder. I place her on adderall, a stimulant combination drug, which seems to help with her behaviour in school. My patient then comes to me because he is experiencing the “tip of the tongue” phenomena more frequently. He is concerned that his word finding difficulty interferes with his ability to function in high level meetings. I suggest we try a cholinesterase inhibitor to see if this helps. I am careful to explain that the Food and Drug Administration does not approve such a use for this medication. He wants to try it and is pleased with the results.A few months later, this patient visits me with his 16 year old son, a talented middle distance runner. His father thinks if he were just a bit better, among the elite high school runners in the state, he would be far more competitive as an applicant for selective colleges. We discuss various options. Because of a recent report that sildenafil, which is used conventionally for male impotence, may improve oxygen carrying capacity, I prescribe this medication. The son does not object.Encouraged by these pharmacologic successes, my patient …. (shrink)

Developments in neuroscience have raised the possibility that pharmaceuticals may be used to enhance memory, mood, and attention in people who do not have an illness or disorder, a practice known as “cognitive enhancement.” We describe historical experiences with two medicinal drugs for which similar enhancement claims were made, cocaine in the late 19th and early 20th centuries, and amphetamines in the mid 20th century. These drugs were initially introduced as medicinal agents in Europe and North America before becoming more (...) widely used for a variety of purposes, including what would nowadays be considered cognitive enhancement. Their trajectory of use conformed to the typical use cycle of psychotropic drugs. There was an initial steep rise in prescribing for medical use, followed by expanded nonmedical use that was fueled by enthusiasm for the drugs’ effects. As the number of regular users increased, problems related to use (such as addiction) became apparent, societal concern increased, and laws were passed banning nonmedical use and eventually, medical use. This historical experience draws attention to the adverse side effects of enhancement use that only become apparent with regular, wide-scale use of a drug. We highlight the similarities between the enthusiasms for cocaine and amphetamines and the current enthusiasms for using prescription stimulants for cognitive enhancement. We argue bioethicists should not encourage the cognitive enhancement use of drugs such as methylphenidate in the absence of evidence on the efficacy and safety of their use for cognitive enhancement purposes. (shrink)

In the debate on the ethics of the non-medical use of pharmaceuticals for cognitive performance enhancement in healthy individuals there is a clear division between those who view “cognitive enhancement” as ethically unproblematic and those who see such practices as fraught with ethical problems. Yet another, more subtle issue, relates to the relevance and quality of the contribution of scholarly bioethics to this debate. More specifically, how have various forms of speculation, anticipatory ethics, and methods to predict scientific trends and (...) societal responses augmented or diminished this contribution? In this paper, we use the discussion of the ethics of cognitive enhancement to explore the positive and negative contribution of speculation in bioethics scholarship. First, we review and discuss how speculation has relied on different sets of assumptions regarding the non-medical use of stimulants, namely: terminology and framing; scientific aspects such as efficacy and safety; estimates of prevalence and consequent normalization; and the need for normative reflection and regulatory guidelines. Second, three methodological guideposts are proposed to alleviate some of the pitfalls of speculation: acknowledge assumptions more explicitly and identify the value attributed to assumptions; validate assumptions with interdisciplinary literature; and adopt a broad perspective to promote more comprehensive reflection. We conclude that, through the examination of the controversy about cognitive enhancement, we can employ these methodological guideposts to enhance the value of contributions from bioethics and minimize potential epistemic and practical pitfalls in this case and perhaps in other areas of bioethical debate. (shrink)

A recent discussion on cognitive enhancers has caused some controversy in the ethics and neuroscience fields by coming out in favour of making neuropharmaceuticals with enhancing properties available for general consumption. We highlight in this brief commentary why concerns regarding efficacy and safety, demands on resources, and public health are substantive enough to warrant serious reconsideration before pharmaceutical performance enhancement can be widely supported.

The development and publication of Diagnostic and Statistical Manual of Mental Disorders, fifth edition produced a peak in mainstream media interest in psychiatry, and a large and generally critical set of scientific commentaries. The coverage has focused mainly on the expansion of some categories, and loosening of some criteria, which together may lead to more people receiving diagnoses, and accompanying accusations of the medicalisation of normal living. Instructions given to members of DSM-5 work groups appear to have encouraged this.1 This (...) has not been the only source of disquiet. The influence of the pharmaceutical industry on the members of the appointees to DSM diagnostic work groups, which constructed the new rubrics, has caused concern,2 as remuneration and insurance coverage in the USA depends partly on DSM diagnosis, and the pharmaceutical industry has been accused of encouraging the development of new diagnoses as a way to increase profitability.3 Societal impact has been an explicit part of the development of DSM-5, as outlined in the article in this issue.4 Reasons for decisions by DSM-5 workgroups have included enabling sufferers to receive treatment which would not be available without a DSM diagnosis , or …. (shrink)

This article presents a model for regulating cognitive enhancement devices. Recently, it has become very easy for individuals to purchase devices which directly modulate brain function. For example, transcranial direct current stimulators are increasingly being produced and marketed online as devices for cognitive enhancement. Despite posing risks in a similar way to medical devices, devices that do not make any therapeutic claims do not have to meet anything more than basic product safety standards. We present the case for extending existing (...) medical device legislation to cover CEDs. Medical devices and CEDs operate by the same or similar mechanisms and pose the same or similar risks. This fact coupled with the arbitrariness of the line between treatment and enhancement count in favour of regulating these devices in the same way. In arguing for this regulatory model, the paper highlights potential challenges to its implementation, and suggests solutions. (shrink)

Davis called for “extreme caution” in the use of non-invasive brain stimulation to treat neurological disorders in children, due to gaps in scientific knowledge. We are sympathetic to his position. However, we must also address the ethical implications of applying this technology to minors. Compensatory trade-offs associated with NIBS present a challenge to its use in children, insofar as these trade-offs have the effect of limiting the child’s future options. The distinction between treatment and enhancement has some normative force here. (...) As the intervention moves away from being a treatment toward being an enhancement—and thus toward a more uncertain weighing of the benefits, risks, and costs—considerations of the child’s best interests diminish, and the need to protect the child’s autonomy looms larger. NIBS for enhancement involving trade-offs should therefore be delayed, if possible, until the child reaches a state of maturity and can make an informed, personal decision. NIBS for treatment, by contrast, is permissible insofar as it can be shown to be at least as safe and effective as currently approved treatments, which are themselves justified on a best interests standard. (shrink)

The present work critically examines two assumptions frequently stated by supporters of cognitive neuroenhancement. The first, explicitly methodological, assumption is the supposition of effective and side effect-free neuroenhancers. However, there is an evidence-based concern that the most promising drugs currently used for cognitive enhancement can be addictive. Furthermore, this work describes why the neuronal correlates of key cognitive concepts, such as learning and memory, are so deeply connected with mechanisms implicated in the development and maintenance of addictive behaviour so that (...) modification of these systems may inevitably run the risk of addiction to the enhancing drugs. Such a potential risk of addiction could only be falsified by in-depth empirical research. The second, implicit, assumption is that research on neuroenhancement does not pose a serious moral problem. However, the potential for addiction, along with arguments related to research ethics and the potential social impact of neuroenhancement, could invalidate this assumption. It is suggested that ethical evaluation needs to consider the empirical data as well as the question of whether and how such empirical knowledge can be obtained. (shrink)

The neural basis of human memory is incredibly complex. We argue that the diversity of neural systems underlying various forms of memory suggests that any discussion of enhancing ‘memory’ per se is too broad, thus obfuscating the biopolitical debate about human enhancement. Memory can be differentiated into at least four major systems with largely dissociable neural substrates. We outline each system, and discuss both the practical and the ethical implications of these diverse neural substrates. In practice, distinct neural bases imply (...) the possibility, and likely the necessity, of specific approaches for the safe and effective enhancement of various memory systems. In the debate over the ethical and social implications of enhancement technologies, this fine-grained perspective clarifies—and may partially mitigate—certain common concerns in enhancement debates, including issues related to safety, fairness, coercion, and authenticity. While many researchers certainly appreciate the neurobiological complexity of memory, the political debate tends to revolve around a monolithic one-size-fits-all conception. The overall project—exploring how human enhancement technologies affect society – stands to benefit from a deeper appreciation of memory’s neurobiological diversity. (shrink)

Transcranial direct current stimulation (tDCS), a simple means of brain stimulation, possesses a trifecta of appealing features: it is relatively safe, relatively inexpensive and relatively effective. It is also relatively easy to obtain a device and the do-it-yourself (DIY) community has become galvanised by reports that tDCS can be used as an all-purpose cognitive enhancer. We provide practical recommendations designed to guide balanced discourse, propagate norms of safe use and stimulate dialogue between the DIY community and regulatory authorities. We call (...) on all stakeholders—regulators, scientists and the DIY community—to share in crafting policy proposals that ensure public safety while supporting DIY innovation. (shrink)

Vigorous debate over the moral propriety of cognitive enhancement exists, but the views of the public have been largely absent from the discussion. To address this gap in our knowledge, four experiments were carried out with contrastive vignettes in order to obtain quantitative data on public attitudes towards cognitive enhancement. The data collected suggest that the public is sensitive to and capable of understanding the four cardinal concerns identified by neuroethicists, and tend to cautiously accept cognitive enhancement even as they (...) recognize its potential perils. The public is biopolitically moderate, endorses both meritocratic principles and the intrinsic value of hard work, and appears to be sensitive to the salient moral issues raised in the debate. Taken together, these data suggest that public attitudes toward enhancement are sufficiently sophisticated to merit inclusion in policy deliberations, especially if we seek to align public sentiment and policy. (shrink)

This article analyzes appropriate public policies for enhancement use of two most important stimulant drugs: Ritalin (methylphenidate) and Adderall (mixed amphetamine salts). The author argues that appropriate regulation of cognition enhancement drugs cannot be a result of a general discussion on cognitive enhancements as such, but has to be made on a case-by-case basis. Starting from the recently proposed taxation approach to cognition enhancement drugs, the author analyzes available, moderately permissive models of regulation. After a thorough analysis of relevant characteristics (...) of methylphenidate and amphetamine, the author concludes that a moderately liberal permissive regulation of enhancement use by healthy adults might be appropriate for extended release forms of methylphenidate. However, due to their danger profile, amphetamine and instant release forms of methylphenidate should not be made readily available to healthy adults and would need to be prohibited. (shrink)

There is mounting evidence that non-invasive brain stimulation devices - transcranial direct current stimulation and transcranial magnetic stimulation could be used for cognitive enhancement. However, the regulatory environment surrounding such uses of stimulation devices is less clear than for stimulant drugs—a fact that has already been commercially exploited by several companies. In this paper, the mechanism of action, uses and adverse effects of non-invasive neurostimulation devices are reviewed, along with social and ethical challenges pertaining to their use as cognitive enhancements. (...) Two regulatory approaches that could be used to facilitate responsible use of these devices as products and services are outlined. Apart from establishing the urgently needed comprehensive regulatory framework, they might provide a starting point for establishing long term physiological and social effects of enhancement uses of tDCS and TMS. (shrink)

There is a growing literature in neuroethics dealing with the problem of cognitive neuroenhancement for healthy adults. However, discussions on this topic have tended to focus on abstract theoretical positions while concrete policy proposals and detailed models are scarce. Furthermore, discussions tend to rely solely on data from the US, while international perspectives are mostly neglected. Therefore, there is a need for a volume that deals with cognitive enhancement comprehensively in three important ways: a) with conceptual implications stemming from different (...) points of view; b) with ethical, social and legal perspectives that would not be limited to one part of the world but reflect on the current situation in countries in Africa, Asia, Australia, Europe, North America and South America; and c) with discussions of concrete law and policy options. Contributors for the conceptual implications section will elaborate an important general issue (e.g. ethical acceptability of direct-to-consumer-marketing in case of cognitive enhancement drugs). Contributors for international perspectives section will provide a clear discussion on normative issues and cultural values, along with an analysis of empirical data on public attitudes on cognitive enhancement and/or prevalence (specific to the country in question). Contributors for law and policy section will offer a justification for the general policy type they argue for (1. prohibition, 2. discourage use, 3. laissez-faire, 4. encourage use, and 5. mandatory use) in the case of specific cognitive enhancement measure. Furthermore, they would evaluate the possible impact of a detailed regulatory model on consumption and demand, fairness in competitive settings and the social pressure to enhance. (shrink)